Tricare Changing Requirements?

[quileness 0]

I was told last week from my surgeons office that they heard that Tricare's requirements may be changing. Instead of the 3 months of dietary consoling it could be going to 6 months. Has anyone else heard this same news?

Tricare has (only in some cases) already forced patients to undergo 6 months of dietary counseling before approving the procedure. If your BMI is over 40, you may not have to do it. At least that's how it was when I was undergoing my approval process last year.

[formykids2 4]

Damander.... if your Dr did documentation on your conventional dieting, get those records! That is what they are looking for. You don't need to talk to your doc to get them either.

[SYRREHS 1]

I never saw a duration, but I haven't done any of those programs..they were too damn expensive. All I know is this is really getting me down. I finally finished all my requirements, only to be told no?

I'm pissed.

I agree about all those programs being so expensive.... it's crazy.....

I can't get over that so called doctor laughed.... report him or her and maybe they will get written up or sent to Siberia....

I spoke with the nurse at the surgeon's office and she suggests (just her own opinion from seeing what others have gone through) that instead of filing an appeal to try going through the Lighten Up program that the hospital provides, she was submitting the papers for the doctor to sign for it, so I hope he does.... I still can't get a duration time that TriCare needs to approve me and that was speaking to someone at TriCare too. (Go figure)

[Pashion 7]

I was told last week from my surgeons office that they heard that Tricare's requirements may be changing. Instead of the 3 months of dietary consoling it could be going to 6 months. Has anyone else heard this same news?

I was approved today by Tricare Prime (west) and I did not have to do six months weight management, but they did come back and say that I have to do it at the local MTF instead of at the clinic I originally choice which is not military.

[Pashion 7]

So I've been going through the steps with my doctor for the surgery and I too have TriCare Prime.... I've had the dietitian evaluation, the phycological evaluation, medical clearance from primary doctor, met with the surgeon twice and last week they submitted the papers for approval. Well within a few days the authorization was denied... saying not medically necessary.... So I call TriCare asking why?????

I said to the customer service agent, "Why would my doctor submit for the precedure if he didn't feel it to be medically necessary?" Also, I asked was there another reason and she said because there was no record of me having any medical treatment such as; Weight Watchers, Jenny Craig and so forth. So I let her know that I have not gone through those programs because I can not afford them for they are very expensive. I've tried Slim Fast, Patches, Dexatrim, Acai berry, counting calories, food log and so forth. I also said that the website for TriCare does not state the medical weight loss programs as a requirement. It says; 100 lbs. over ideal weight and atleast one associated condition; such as high blood pressure (in which I have).... Is 200 % or more over ideal weight or Has had intestinal bypass or other surgery for obesity.

In another area regarding Bariatric surgery it says the Lap Band is a covered benefit that requires prior authorization and medical necessity review. Pre-surgical psychological evaluation and testing is covered. Pre-surgical nutritional counseling should be performed by staff in the provider's office and is not covered if requested separately. No mention of medical weight loss programs.... All she could say after that is that I can appeal the denial and that she can not see what a beneficiary sees on their side of the computer system.... GGRRRRR

I put a call into my doctor (surgeon) to find out if they have come across this before. I left a message and I'm awaiting a reply.

I know I'm going on and on but this is driving crazy..... Has anyone heard of this requirement for TriCare?

I have Tricare Prime (west) and my paperwork was submitted to Tricare yesterday and I was approved today. I did not do any type of six months weight management I saw the surgeon on Sept 20th and today is Oct 25th. This is what was submitted to Tricare: psych eval and nutritionist eval, notes from my PCM showing that I took phentermine for one month back in April of this year and it did not work, and my sleep apnea results showing that I was diagnosed back in Oct of 2010 with sleep apnea, my bmi is 38.6. My only issue is because I was doing all of this thru a civilian surgeon Tricare has now come back and said I have to have the surgery done at the MTF. I do not know if the MTF is going to make me do six months weigt management but I do know that as of today that is not required by Tricare but you do need to show that you have tried something and it did not work. I guess for me using the phentermine diet pills helped me out. Who really knows when it comes to Tricare.

[SYRREHS 1]

I bet the diet pills helped out and that you were going through a doctor for them. I did mine without a doctor. This is a very helpful way to find out what needs to be done and correctly to help get an approval. Thank you..... Please let me know how things are going for you and if you ever need anyone to talk with I'm here... 8 ]

I'm going to call my doctor's office tomorrow to see if he signed the papers for me to start the Lighten Up program and I can get started and hopefully find out soon if they (TriCare) needs 3 or 6 months for the medical treatment. I just want to get it completed and hope and pray that that is all TriCare needs and won't change their mind and add something else.

Have a Super Day......

I have Tricare Prime (west) and my paperwork was submitted to Tricare yesterday and I was approved today. I did not do any type of six months weight management I saw the surgeon on Sept 20th and today is Oct 25th. This is what was submitted to Tricare: psych eval and nutritionist eval, notes from my PCM showing that I took phentermine for one month back in April of this year and it did not work, and my sleep apnea results showing that I was diagnosed back in Oct of 2010 with sleep apnea, my bmi is 38.6. My only issue is because I was doing all of this thru a civilian surgeon Tricare has now come back and said I have to have the surgery done at the MTF. I do not know if the MTF is going to make me do six months weigt management but I do know that as of today that is not required by Tricare but you do need to show that you have tried something and it did not work. I guess for me using the phentermine diet pills helped me out. Who really knows when it comes to Tricare.

[Damander 11]

Ok, so everything worked in my favor because I was approved today!!

I am 5'0, 214 lbs NO comorbidity, BMI was a little over 40 and that's that! Approval was simple!!

Good luck!!

[Fat-2-Phat 1]

Ok, so everything worked in my favor because I was approved today!!

I am 5'0, 214 lbs NO comorbidity, BMI was a little over 40 and that's that! Approval was simple!!

Good luck!!

Yay! I'm excited for you and it seems like your approval came back reasonably quick. I will submit my paperwork next Tues, Nov 1 and I'll be praying and keeping my fingers crossed. Your post gave me hope and I remain optimistic for similiar results. Best of luck...when's your surgery date? I'm hoping I can schedule Dec 21st.

Peg

[Damander 11]

Yay! I'm excited for you and it seems like your approval came back reasonably quick. I will submit my paperwork next Tues, Nov 1 and I'll be praying and keeping my fingers crossed. Your post gave me hope and I remain optimistic for similiar results. Best of luck...when's your surgery date? I'm hoping I can schedule Dec 21st.

Peg

It took forever to get clearance from the doctors with all that I had going on, but yea-they submitted to Tricare on Monday and I checked the website daily and this morning there was an approval so it did go relatively fast! Definitely stay positive and if you do have co-morbidities, just know that its usually an automatic approval! Good luck to you!!!

[Pashion 7]

I bet the diet pills helped out and that you were going through a doctor for them. I did mine without a doctor. This is a very helpful way to find out what needs to be done and correctly to help get an approval. Thank you..... Please let me know how things are going for you and if you ever need anyone to talk with I'm here... 8 ]

I'm going to call my doctor's office tomorrow to see if he signed the papers for me to start the Lighten Up program and I can get started and hopefully find out soon if they (TriCare) needs 3 or 6 months for the medical treatment. I just want to get it completed and hope and pray that that is all TriCare needs and won't change their mind and add something else.

Have a Super Day......

How are things going with you? I am now playing the waiting game. The Military hosp. is now saying that they do not have any surgeons available to even do an consult with me. It pissed me off because I could have had my surgery done at the civilian hosp this coming Friday. Now I have to wait until the 22nd of this month before the Military hosp. will send approval to Tricare for me to be able to have the surgery done at the civilian hosp. They have this policy that you have to wait 28 days to see if a surgeon becomes available and if not then at that time they will outsource you. I am so disgusted.